Bisphosphonate-Related Osteonecrosis of the Jaw and Oral Microbiome: Clinical Risk Factors, Pathophysiology and Treatment Options.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) represents a serious health condition, impacting the lives of many patients worldwide. The condition challenges clinical care due to its complex etiology and limited therapeutic options. A thorough understanding of the pathophysiological and patient-related factors that promote disease development is essential. Recently, the oral microbiome has been implicated as a potential driver and modulating factor of BRONJ by several studies. Modern genomic sequencing methods have provided a wealth of data on the microbial composition of BRONJ lesions; however, the role of individual species in the process of disease development remains elusive. A comprehensive PubMed search was conducted to identify relevant studies on the microbiome of BRONJ patients using the terms "microbiome", "osteonecrosis of the jaws", and "bisphosphonates". Studies focusing on symptoms, epidemiology, pathophysiology, risk factors, and treatment options were included. The principal risk factors for BRONJ are tooth extraction, surgical procedures, and the administration of high doses of bisphosphonates. Importantly, the oral microbiome plays a significant role in the progression of the disease. Several studies have identified alterations of microbial composition in BRONJ lesions. However, there is no consensus regarding bacterial species that are associated with BRONJ across studies. The bacterial genera typically found include Actinomyces, Fusobacterium, and Streptococcus. It is postulated that these microbes contribute to the pathogenesis of BRONJ by promoting inflammation and disrupting normal bone remodeling processes. Current therapeutic approaches are disease-stage-specific and the necessity for more effective treatment strategies remains. This review examines the potential causes of and therapeutic approaches to BRONJ, highlighting the link between microbial colonization and BRONJ development. Future research should seek to more thoroughly investigate the interactions between bisphosphonates, the oral microbiome, and the immune system in order to develop targeted therapies.

Oral side effects of COVID-19 vaccines in 32 European countries: Analysis of EudraVigilance reports.

The recent reports of oral side effects (SEs) following COVID-19 vaccination warrant further investigation into their prevalence, severity, and aetiology. This study was conducted to synthesize the first-ever population-level evidence about oral SEs of COVID-19 vaccines in Europe. The European Union Drug Regulating Authorities Pharmacovigilance (EudraVigilance) database was accessed in August 2022 to extract summary data of all potential oral SEs reported after COVID-19 vaccination. The data were reported descriptively and cross-tabulated to facilitate sub-group analysis per vaccine type, sex, and age group. Dysgeusia was the most commonly reported oral SE (0.381 case per each 100 received reports), followed by oral paraesthesia (0.315%), ageusia (0.296%), lip swelling (0.243%), dry mouth (0.215%), oral hypoaesthesia (0.210%), swollen tongue (0.207%), and taste disorder (0.173%). Females had significantly (Sig. < 0.001) a higher prevalence of all most common (top 20) oral SEs, except for salivary hypersecretion, which was equally prevalent among females and males. The present study revealed a low prevalence of oral SEs, with taste-related, other sensory and anaphylactic SEs being the most common SEs in Europe, similar to what was found earlier among the US population. Future studies should explore the potential risk factors of oral sensory and anaphylactic SEs to verify whether they are causally linked to COVID-19 vaccines.

Pain perception following computer-controlled versus conventional dental anesthesia: randomized controlled trial.

BACKGROUND: The administration of local anesthesia (LA) in dental practice requires an injection which is the leading cause of patients' fear and anxiety. Computer-controlled local anesthetic injector, designed to reduce the pain of performing local anesthesia by controlling the speed of injection. This single-blind randomised control trial aimed to compare the pain perception after computer-controlled local anesthesia (CCLA) and conventional LA. METHODS: Dental students were both test and operator group versus an experienced dentist as additional operator of the LA. Data were collected regarding gender, age, medical condition, smoking habits. Additionally, operator feedback about the handling, pain at insertion and during infiltration, excitement (Dental Anxiety Scale), and complications were assessed. RESULTS: Out of the 60 included participants, the majority were females (n = 41; 68.3%), medically healthy (n = 54; 90%), and did not receive medications (n = 54; 90%). While the participating students administered 62 (51.7%) injections, the experienced dentist administered 58 (48.3%) injections. The difference in pain perception on puncture between CCLA and conventional injections was not statistically significant (Sig. = 0.285); however, pain perception during injection was significantly different (Sig. = 0.029) between CCLA (1.65 ± 1.93) and conventional injections (2.49 ± 2.31). CONCLUSION: The professional experience influenced the pain perception while applying the LA. CCLA did not reduce pain on puncture significantly; however, pain perception during the injection was significantly reduced in the case of using CCLA devices compared to the conventional syringe.

Knowledge of dental academics about the COVID-19 pandemic: a multi-country online survey.

BACKGROUND: COVID-19 is a global pandemic affecting all aspects of life in all countries. We assessed COVID-19 knowledge and associated factors among dental academics in 26 countries. METHODS: We invited dental academics to participate in a cross-sectional, multi-country, online survey from March to April 2020. The survey collected data on knowledge of COVID-19 regarding the mode of transmission, symptoms, diagnosis, treatment, protection, and dental treatment precautions as well as participants' background variables. Multilevel linear models were used to assess the association between dental academics' knowledge of COVID-19 and individual level (personal and professional) and country-level (number of COVID-19 cases/ million population) factors accounting for random variation among countries. RESULTS: Two thousand forty-five academics participated in the survey (response rate 14.3%, with 54.7% female and 67% younger than 46 years of age). The mean (SD) knowledge percent score was 73.2 (11.2) %, and the score of knowledge of symptoms was significantly lower than the score of knowledge of diagnostic methods (53.1 and 85.4%, P <  0.0001). Knowledge score was significantly higher among those living with a partner/spouse than among those living alone (regression coefficient (B) = 0.48); higher among those with PhD degrees than among those with Bachelor of Dental Science degrees (B = 0.48); higher among those seeing 21 to 30 patients daily than among those seeing no patients (B = 0.65); and higher among those from countries with a higher number of COVID-19 cases/million population (B = 0.0007). CONCLUSIONS: Dental academics had poorer knowledge of COVID-19 symptoms than of COVID-19 diagnostic methods. Living arrangements, academic degrees, patient load, and magnitude of the epidemic in the country were associated with COVD-19 knowledge among dental academics. Training of dental academics on COVID-19 can be designed using these findings to recruit those with the greatest need.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 1: Epidemiology, Genetics and Diagnosis.

Basal cell carcinoma is the most common malignant tumor among fair-skinned individuals, and its incidence has been rising steadily in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 1 highlights new developments in genetics in particular as well as aspects regarding epidemiology, diagnosis, and histology.

S2k Guidelines for Cutaneous Basal Cell Carcinoma - Part 2: Treatment, Prevention and Follow-up.

Basal cell carcinoma (BCC) is the most common malignant tumor among fair-skinned individuals, and its incidence had been steadily rising in the past decades. In order to maintain the highest quality of patient care possible, the German S2k guidelines were updated following a systematic literature search and with the participation of all professional societies and associations involved in the management of the disease. Part 2 addresses issues such as proper risk stratification, the various therapeutic approaches, and prevention as well as follow-up of patients with basal cell carcinoma.

Treated Versus Untreated Positional Head Deformity.

BACKGROUND: Positional head deformity in early childhood is asserted to be a benign and in some cases spontaneously correcting entity encountered in craniofacial surgery. Although many authors have stated that helmet therapy is indicated in moderate and severe cases of deformational plagiocephaly and brachycephaly; others have reported resolution of these conditions within the first 2 to 3 years of life. A recent randomized controlled trial found that helmet therapy does not have beneficial effects for patients with positional head deformity. METHODS: The authors evaluated the clinical course of positional cranial deformation during a period of 5 years and compared the anthropometric parameters of orthotically treated versus untreated children within this timeframe. RESULTS: Although the patients were matched with respect to their cranial deformation at baseline, there were significant differences in the cranial vault asymmetry (CVA), cranial vault asymmetry index (CVAI), and oblique cranial length ratio (OCLR) between Groups 1 and 2 at the initial point (P < 0.05). The mean CVA was 0.95 cm in Group 1 (no helmet) and 1.74 cm in Group 2 (helmet). The mean CVAI at baseline was 7.25 for Group 1 and 13.77 for Group 2. Approximately 5 years after the first examination, the authors found clear improvement in the mean CVA in Group 2 (ΔCVA 1.35 cm) compared with Group 1 (ΔCVA 0.01 cm) and the mean CVAI. CONCLUSIONS: In contrast to recently published studies, the authors found clear improvement in nonsynostotic head deformity treated with an individual molding helmet and no clear evidence of improvement of absolute measurements in untreated cranial deformity within a 5-year follow-up period.

Measuring and Comparing the Cost-Effectiveness of Surgical Care Delivery in Low-Resource Settings: Cleft Lip and Palate as a Model.

Cleft lip and palate (CLP) care is the longest sustained global effort in humanitarian surgical care. However, the relative cost-effectiveness of surgical delivery approaches remains largely unknown. We assessed the cost-effectiveness of two strategies of CLP surgical care delivery in low resource settings: medical mission and comprehensive care center. We evaluated the medical records and costs for 17 India-based medical missions and a Comprehensive Cleft Care Center in Guwahati, India, from Operation Smile, a humanitarian nongovernmental organization. Age, sex, diagnosis, and procedures were extracted and cost/Disability-Adjusted Life Year (DALY) averted was calculated using a provider's perspective. The disability weights for CLP from the Global Burden of Disease (GBD) 2010 update were used as the reference case. Sensitivity analysis was performed using various disability weights, age-weighting, discounting, and cost perspective. The medical missions treated 3503 patients for first-time cleft procedures and averted 6.00 DALYs per intervention with a cost-effectiveness of $247.42/DALY. The care center cohort included 2778 patients with first-time operations for CLP and averted a mean of 5.96 DALYs per intervention with a cost-effectiveness of $189.81/DALY. The Incremental Cost-Effectiveness Ratio (ICER) of choosing medical mission over care center is $462.55. The care center provides cleft care with a higher cost-effectiveness, although both models are highly cost-effective in India, in accordance with WHO guidelines. Compared to other global health interventions, cleft care is very cost-effective and investment in cleft surgery might be realistic and achievable in similar resource-constrained environments.

Estimation of legal age using calcification stages of third molars in living individuals.

The increased number of adolescents and young adults with unknown or inaccurately given date of birth is a current issue in justice and legal medicine. The objective of this study was to determine the extent to which third molar calcification stages assessed on panoramic X-rays could be useful as additional criteria for forensic age estimation in living individuals, focusing on the legally important ages 17 and 18. In a retrospective multi-center study, the developmental stage of each individual's third molar was analyzed using Demirjian's scale in 2360 cases. Additionally, sex, age and ancestry were assessed. Individuals with the lowest calcification stage of all present molars in stage H were ≥18 years with a likelihood of ≥99.05% in the female (n=388), and ≥99.24% in the male (n=482) population. The lowest calcification stage of all present third molars proved to be useful as an additional reliable criterion for the determination of an age ≥18 years.

A prospective randomized trial on preventative methods for positional head deformity: physiotherapy versus a positioning pillow.

OBJECTIVE: To evaluate the impact of stretching exercises versus available bedding pillows on positional head deformities. STUDY DESIGN: Fifty children aged 5 months or younger with positional head deformity were included in this prospective clinical trial (n=20 plagiocephaly, n=10 brachycephaly, n=20 combination). A random distribution was performed for treatment with the bedding pillow alone (n=25) or with stretching exercises (n=25) for 6 weeks. Anthropometric caliper measurements were done before and after that interval. Cranial vault asymmetry index (CVAI) and cranial index (CI) were calculated and analyzed using a descriptive statistical general linear model. RESULTS: ΔCVAI in the stretching group was 2.09% for plagiocephaly and 2.34% for combined head deformities. Using the bedding pillow, ΔCVAI was 3.01% in plagiocephal children and 2.86% for combined head deformity. The ΔCI in the stretching group was 0.94% for isolated brachycephal children and 2.24% for combined head deformity. ΔCI in the pillow group was 3.63% for brachycephaly and 3.23% in children with combined head deformities, respectively. CONCLUSIONS: Bedding pillows and stretching exercises both resulted in improvements in positional cranial deformation. For children with combined plagiocephaly and brachycephaly, improvement in cranial asymmetry was slightly greater when using bedding pillows versus stretching.

Adjuvant Radiotherapy in Patients with Squamous Cell Carcinoma of the Oral Cavity or Oropharynx and Solitary Ipsilateral Lymph Node Metastasis (pN1)-A Prospective Multicentric Cohort Study.

(1) Background: Evaluation of impact of adjuvant radiation therapy (RT) in patients with oral squamous cell carcinoma of the oral cavity/oropharynx (OSCC) of up to 4 cm (pT1/pT2) and solitary ipsilateral lymph node metastasis (pN1). A non-irradiated group with clinical follow-up was chosen for control, and survival and quality of life (QL) were compared; (2) Methods: This prospective multicentric comprehensive cohort study included patients with resected OSCC (pT1/pT2, pN1, and cM0) who were allocated into adjuvant radiation therapy (RT) or observation. The primary endpoint was overall survival. Secondary endpoints were progression-free survival and QL after surgery; (3) Results: Out of 27 centers, 209 patients were enrolled with a median follow-up of 3.4 years. An amount of 137 patients were in the observation arm, and 72 received adjuvant irradiation. Overall survival did not differ between groups (hazard ratio (HR) 0.98 [0.55-1.73], p = 0.94). There were fewer neck metastases (HR 0.34 [0.15-0.77]; p = 0.01), as well as fewer local recurrences (HR 0.41 [0.19-0.89]; p = 0.02) under adjuvant RT. For QL, irradiated patients showed higher values for the symptom scale pain after 0.5, two, and three years (all p < 0.05). After six months and three years, irradiated patients reported higher symptom burdens (impaired swallowing, speech, as well as teeth-related problems (all p < 0.05)). Patients in the RT group had significantly more problems with mouth opening after six months, one, and two years (p < 0.05); (4) Conclusions: Adjuvant RT in patients with early SCC of the oral cavity and oropharynx does not seem to influence overall survival, but it positively affects progression-free survival. However, irradiated patients report a significantly decreased QL up to three years after therapy compared to the observation group.

Clinical classification of infant nonsynostotic cranial deformity.

OBJECTIVE: Based on a pilot study including >400 children and a comprehensive database analysis of >2500 children, we sought to define the craniofacial norm and to objectify the categorization of positional head deformity. STUDY DESIGN: A database was created containing clinical information on children assessed for nonsynostotic cranial deformity. The findings of standardized anthropometric measurements were compared with data from a group of 401 healthy children with a normal head shape collected in terms of a prospective pilot study. Using a statistical analysis of all anthropometric craniofacial measurements, cut-off percentiles for discriminating different groups of deformation and severity classes were generated. RESULTS: Normative percentiles for all dimensions in cranial vault anthropometric measurements during the first year of life were calculated. Children with definite nonsynostotic head deformity could be clearly allocated into 3 different groups: positional plagiocephaly (abnormal Cranial Vault Asymmetry Index), positional brachycephaly (abnormal Cranial Index), and combined positional plagiocephaly and brachycephaly (abnormal Cranial Vault Asymmetry Index and Cranial Index). Additionally, a reliable 3-level severity categorization (mild, moderate, and severe) for each group of cranial deformation could be obtained according to age and sex. CONCLUSIONS: Our results allow a meaningful and reliable classification of nonsynostotic early childhood cranial deformity.

Prevalence and Drivers of COVID-19 Vaccine Booster Hesitancy Among German University Students and Employees.

COVID-19 booster hesitancy (VBH) is a serious public health challenge which acts simultaneously with the waning vaccine-elicited immunity and the emerging viral variants to prolong the pandemic interval. Therefore, this study aimed to evaluate the prevalence of COVID-19 VBH among a highly educated subset of the German population and to explore the potential demographic, anamnestic, and psychosocial determinants of this problem. A cross-sectional survey-based study was conducted in December 2021 among German university students and employees to evaluate their attitudes toward COVID-19 vaccine booster (VB) doses. The study used a self-administered questionnaire that was developed and disseminated digitally, and the questionnaire inquired about participants' demographic characteristics, COVID-19-related anamnesis, COVID-19 vaccine-related anamnesis, and psychosocial predictors of COVID-19 VBH. A total of 930 participants were recruited, of which 608 (65.4%) were students, 682 (73.3%) were females, and their mean age was 29.08 ± 10.93 years. Fifty-five participants (5.9%) had been previously infected by COVID-19 and the vast majority of infections happened before the first vaccine dose. Over 95% of the participants had received at least one vaccine dose, and the most commonly administered vaccine was BNT162b2. The overall COVID-19 VB acceptance was satisfactory (87.8%) and induced by various altruistic promoters, e.g., family health protection, community health protection, and patients' health protection. The students (86.3%), the previously infected participants (76.4%), the participants who did not receive primer doses of COVID-19 vaccines (2.5 %), and those who were hospitalized (40%) and sought medical care/treatment after receiving primer doses (86.8%) were less likely to accept COVID-19 VB compared to the employees (90.7%), the participants who were not previously infected (88.6%) and those who received primer dose (91.7%), and the participants who were not hospitalized (92%) nor sought medical care/treatment after primer doses (92.9%), respectively. The perceived effectiveness of COVID-19 VB against severe illness (adjusted odds ratio "AOR": 47.65-95% confidence interval "CI": 23.65-96.49), symptomatic infection (AOR: 9.87-95% CI: 5.20-18.71), community transmission (AOR: 5.34-95% CI: 3.00-9.49) and emerging variants (AOR: 19.12-95% CI: 10.57-34.55) were key predictors for COVID-19 VB acceptance; therefore, it needs to be highlighted in vaccine messaging. In addition, the perceived safety of COVID-19 VB and ethical dilemmas of vaccine justice need to be addressed publicly.

Oral Health Knowledge, Attitudes, and Behaviors (KAB) of German Dental Students: Descriptive Cross-Sectional Study.

Germany's 2030-oral health agenda incorporates behavioral targets such as twice-daily toothbrushing and routine dental check-ups. Given the professional and social roles of dentists in oral health promotion, the oral health-related knowledge, attitudes, and behaviors (KAB) of dentists and dental students became worth investigation. The present study was designed as a descriptive cross-sectional study that aimed to evaluate oral health KAB of German dental students using the Hiroshima University - Dental Behavioral Inventory (HU-DBI). A total of 508 dental students filled in the questionnaire, out of which 74.2% were females, 38.8% were clinical students, 11.4% reported tobacco smoking at least once week, 26.6% reported drinking alcohol at least once a week, and 82.9% reported suffering from problematic internet use. The overall HU-DBI score was high (7.67 ± 1.32), and it was slightly higher among females (7.70 ± 1.33) than males (7.59 ± 1.29), and gender-diverse students (7.33 ± 1.37). Clinical students (7.88 ± 1.26) had a significantly higher HU-DBI score, especially in the domain of oral health behaviors, compared with preclinical students (7.53 ± 1.34). A significant improvement in oral health behaviors and HU-DBI score was found between the third- vs. the fourth year, which corresponds to the period when prophylaxis, hygiene, and periodontology courses are delivered. Tobacco smoking was significantly associated with poor oral health knowledge, behaviors, and overall HU-DBI score. Problematic internet use and alcohol drinking had slightly lower HU-DBI scores. The findings of the present study call for early implementation of preventive dentistry elements in German curricula and addressing oral health needs of gender minorities in Germany by future epidemiologic studies.

Estonian Dental Students' Oral Health-Related Knowledge, Attitudes and Behaviours (KAB): National Survey-Based Study.

The strategic plan for dentistry and oral health in Estonia of 2030 focuses on oral health promotion and disease prevention through undergraduate dental curricula and fostering public health-oriented research among students. The present study was designed as a descriptive cross-sectional study to evaluate oral health-related knowledge, attitudes, and behaviours (KAB) of dental students in Estonia. The study was carried out in the spring semester of 2020, and it used a modified version of the Hiroshima University Dental Behavioural Inventory (HU-DBI). A total of 129 students responded to the survey, constituting a response rate of 93.5% due to the total population sampling (census) technique used in this study and the small target population size. Out of the 124 students included in the final analysis, 79% were females, 62.1% were clinical students, 11.3% reported smoking tobacco at least once a week, and 86.3% reported problematic internet use. The present study found that mean HU-DBI score of Estonian dental students was 8.09 ± 1.22 which is so far the highest recorded HU-DBI score in Europe. There was no significant difference between female vs. male or preclinical vs. clinical students in terms of HU-DBI score. While clinical students reported less faulty oral hygiene practices, such as hard toothbrush use and aggressive toothbrushing, preclinical students reported a slightly higher mean HU-DBI score. Smoking behaviour was more common among male and clinical students, and it was also associated with alcohol drinking and worry about teeth colour and halitosis.

Osseous Union after Jaw Reconstruction with Fibula-Free Flap: Conventional vs. CAD/CAM Patient-Specific Implants.

This is a monocentric, retrospective study of patients who underwent successful immediate or delayed maxilla or mandible reconstructions with FFF from January 2005 to December 2021. Panoramic radiograph, computed tomography scans, and cone-beam CTs were analyzed concerning the osseous union of the intersegmental junctions between maxillary or mandibular native jaw and fibular bone. The primary parameter was to estimate the status of osseous union according to osteosynthesis type. A total number of 133 patients (PSI: n = 64, non-PSI: n = 69) were included in the present study. The mean age was 56.7 ± 14.0 (Range: 14.7−82.7); the primary diagnosis was in 105 patients a malignant (78.9%) and in 20 patients a benign (15.0%) tumor. Mandible reconstruction was performed on 103 patients (77.4%), and on 30 patients (22.6%), maxilla reconstruction was performed. The radiographic images provided a rate of incomplete osseous union (IOU) of about 90% in both groups in the first 6 months. Imaging between 6 and 12 months reveals an IOU rate in the non-PSI group of 46.3% vs. 52.5% in the PSI group, between 12 and 24 months, an IOU rate of 19.6% vs. 26.1%, between 24 and 36 months 8.9% vs. 21.7%, and after 36 months the IOU rate decreases to 4.2% vs. 18.2%. Multivariate logistic regression shows that only osteosynthesis type (OR = 3.518 [95%-CI = 1.223−10.124], p = 0.02) and adjuvant radiotherapy (OR = 4.804 [95%-CI = 1.602−14.409], p = 0.005) are independent risk factors for incomplete osseous union. Cox regression revealed that the variables plate-system (Hazard ratio, HR = 5.014; 95 %-CI: 1.826−3.769; p = 0.002) and adjuvant radiotherapy (HR = 5.710; 95 %-CI: 2.066−15.787; p < 0.001) are predictors for incomplete osseous union. In our study, the rate of incomplete bony fusion was significantly higher in the PSI group. Jaw-to-fibula apposition zones were significantly more affected than intersegmental zones. In multivariate analysis, a combination of osteosynthesis with PSI and adjuvant radiotherapy could be identified as a risk constellation for incomplete ossification.

Osseous Union after Mandible Reconstruction with Fibula Free Flap Using Manually Bent Plates vs. Patient-Specific Implants: A Retrospective Analysis of 89 Patients.

The aim of this monocentric, retrospective clinical study was to evaluate the status of osseous union in uni- and poly-segmental mandible reconstructions regarding conventional angle-stable manually bent osteosynthesis plates (Unilock 2.0 mm) versus titan laser-melted PSI patient-specific implant's (PSI). The clinical impact of PSI's high stiffness fixation methods on bone healing and regeneration is still not well addressed. The special interest was in evaluating the ossification of junctions between mandible and fibula and between osteotomized fibula free flap (FFF) segments. Panoramic radiograph (OPT), computed tomography (CT) scans, or cone-beam CTs (CBCT) of patients who underwent successful FFF for mandible reconstruction from January 2005 to December 2020 were analyzed. A total number of 89 cases (28 females (31.5%), 61 males (68.5%), mean age 58.2 ± 11.3 years, range: 22.8-82.7 years) fulfilled the chosen inclusion criteria for analysis (conventional: n = 44 vs. PSI: n = 45). The present study found an overall incomplete ossification (IOU) rate of 24.7% (conventional: 13.6% vs. PSI: 35.6%; p = 0.017) for mandible to fibula and intersegmental junctions. Between osteotomized FFF segments, an IOU rate of 16% was found in the PSI-group, while no IOU was recorded in the conventional group (p = 0.015). Significant differences were registered for IOU rates in poly-segmental (p = 0.041), and lateral (p = 0.016) mandibular reconstructions when PSI was used. Multivariate logistic regression analysis identified plate exposure and type of plate used as independent risk factors for IOU. Previous or adjuvant radiotherapy did not impact incomplete osseous union in the evaluated study sample. PSI is more rigid than bent mini-plates and shields functional mechanical stimuli, and is the main reason for increasing the rate of incomplete ossification. To enhance the functional stimulus for ossification it has to be discussed if patient-specific implants can be designed to be thinner, and should be divided into segmental plates. This directs chewing forces through the bone and improves physiological bone remodeling.